Baroness Hayman: My Lords, I assure the noble Lord that it is the Government's intention to achieve a voluntary system of price regulation. The incidents which he described strike a chord with me. I was a Member of another place at the time when the legislation to which he refers was debated. My

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constituency had considerable pharmaceutical industry interests and I was party to some of the debates and arguments at that time.

Lord Lyell: My Lords, I compliment the Minister. I do not know whether the noble Baroness, as a lay person, is involved in science and the law. Certainly I am neither a scientist nor lawyer; I am a mere accountant. If one gets involved with patents and in particular pharmaceuticals, one can find oneself in considerable difficulty. I believe that at that time the Minister represented Welwyn and Hatfield.

In July 1998 the PPRS was given considerable praise by the Minister's right honourable friend in another place. In a reply in October last year the noble Baroness appeared to apply the brakes slightly. I believe she said at that time that she looked forward to full compliance with the scheme and more transparency. I hope that under the existing scheme there are enough avenues by which the Government and the Secretary of State can discuss what is and what is not reasonable price or profit, let alone transparency, in the figures and costs. I am sure the noble Baroness and her right honourable friend are aware that, in looking at prices, profits and return on capital, one is attempting to aim at a moving target, because most of the large pharmaceutical companies have global interests.

Perhaps I may be the first speaker today to ask the noble Baroness to glance at the happy pale green paper--the Bill. The noble Baroness will see that Clause 27 bears the title "Power to control prices". That is absolutely fine. However, one wonders why there is to be a power to control prices. From the studies that I have made and the representations that I have received over the years, the pharmaceutical industry has looked at return on capital and profits as well as prices. Is this a new departure?

I ask the noble Baroness to look at Clause 28(4) which states:

"The scheme may provide for any amount representing sums charged".

Is that meant to be prices? If not, does it mean something else? Perhaps the noble Baroness can write to me about that or perhaps we can return to it at Committee stage. In subsection (5) reference is made to "amount representing the profits". That appears to me to be very much the language of the existing scheme. The scheme has developed under all governments over the past 42 years.

Clauses 26 to 30 remind me of the philosophy of the great football team that I know is supported by the family of the noble Baroness. Much of its attitude can be described as "fee-fi-fo-fum". It tends to put itself forward in that way. Perhaps the noble Baroness will turn to Clause 31. Subsection (3) makes reference to the power to make regulations,

"under any of those provisions or section 30 may be exercised generally ..."

That removes half of the "fee-fi-fo-fum" and threat. One wonders what "generally" means and whether her great football team is turning into a team of tabby cats.

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However, in subsection (4) one sees that the powers conferred may be controlled by reference to the

"prices or profits which would be reasonable in all the circumstances".

That appears to remove most of the threat or in terrorem of Clauses 26 to 31. Indeed, the football team may be tabby cats that roll over to have their tummies tickled.

One wonders how the last two subsections of the clause can be reconciled with some of the thoughts and remarks made about the Pharmaceutical Price Regulation Scheme. Alas, when I rose to my feet the noble Lord, Lord Macdonald of Tradeston, was not here. However, perhaps he or the noble Baroness can advise me on one matter. I believe that the PPRS now applies to Scotland or that it is intended to do so with the coming into being of the Scottish Parliament. Perhaps I can be advised as to that. If not, I can return to it at Committee stage.

I should like to touch on two other subjects: first, what may be described as the rationing of healthcare. There are continuing discoveries in both medicine and medical practice. One always finds new cures and remedies for existing diseases. I remember one example in my home town of Angus which is very relevant to Scotland. I understand that beta-interferon can considerably help those who suffer from multiple sclerosis. One particular friend who suffered from this condition discovered that he was unable to have treatment with beta-interferon because he lived in Angus but that had he lived in Fife or other areas where there were different views about the clinical effectiveness of this treatment he would have received it. That is one particular problem that perhaps we will be able to consider. I am sure that the Government take that on board. It is an aspect to which I may return in Committee.

The last item to which I refer is waiting lists. This is always a point of discussion that tends to evoke a considerable amount of heat in your Lordships' House. My noble friend Lord Skelmersdale made reference to this matter in his speech. I read about waiting lists for elective surgery. But space must also be reserved in hospitals for winter and summer emergencies. If one watches television or listens to the radio in the summer one is told that the pollen count will be so much. There are also winter emergencies. As to the latter, five weeks ago today I was not in your Lordships' House but skiing in Switzerland. At 10 o'clock in the morning an emergency helicopter arrived. I and others were informed that it had picked up someone who turned out to be my noble friend Lord Astor. Five weeks ago he suffered a winter emergency. Thanks to the wonderful treatment that he received in Switzerland we see him back here thriving and alert with the occasional clatter of crutches, which is by the by. That is a typical winter emergency which can happen elsewhere. But if a winter emergency occurred anywhere within the National Health Service I am sure that it could provide as good a treatment as that received by my noble friend.

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I may be about to be visually challenged because I am now into my fourteenth minute. I very much welcome parts of the Bill. I shall have a little more to ask the noble Baroness in the course of Committee stage. I thank her for presenting the Bill so clearly today.

7.20 p.m.

Lord Rea: My Lords, as the penultimate "run of the mill" speaker, I shall be brief and stick to the substance of the Bill. If I were sitting on the other side of the Chamber, I should probably describe the Bill as a "ragbag" of assorted fragments of legislation. However, as a loyal supporter of the Government, I should welcome it as a treasure chest full of finely crafted gifts. In fact it is more like a lucky dip in that while feeling around at the bottom of the bran tub one can discern the general outline of its separate packages, but the detail is a little less easy to make out.

In his reasoned amendment, the noble Earl, Lord Howe, is critical of the lack of detail in certain clauses relating to primary care trusts. I find his amendment rather grandiose in its wording. It calls for government amendments, but as the noble Lord, Lord Clement-Jones, and others have pointed out, surely the time for that is during the next three stages. Is that not their very purpose? I am sure my noble friend would be helpful and accommodating about the Bill if approached in a constructive way by the noble Earl, possibly outside the Chamber. The noble Earl's amendment may be unnecessarily confrontational, in particular at this early stage. There seems to be quite a lot of meat about the structure of primary care trusts in the relevant clauses, Clause 1 to 7, and in Schedule 1 as well as in the existing legislation to which the Bill refers appropriately, as the Minister pointed out.

However, I have to report that the British Medical Association is rather unhappy about the omission of some details. Perhaps the Minister could be a little clearer in her explanation of why, for instance, the detailed composition of primary care trust management boards has not been spelt out on the face of the Bill. I am sure she has read the comments of the BMA, but for the record it says:

"It is essential that healthcare professionals have the same level of input to, and influence over, the development of local health services as they have been given in Primary Care Groups"--

which of course are now taking shape throughout the country without any special need for legislation. Further BMA concerns about omissions from the primary care trust clauses as they stand include the future status of the local medical committees as representing all local GPs, and the mechanisms for seeking professional advice on commissioning decisions. Other noble Lords have mentioned that.

A particular point that needs to be addressed is the need for high quality public health advice, both in measuring and assessing the health needs of the population through epidemiological expertise, and in contributing to health improvement programmes. The BMA is anxious to know whether the Government intend to make it a statutory duty of a PCT to involve

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healthcare professionals in decision making as it is with other health authorities. It would be helpful if my noble friend can state the Government's intentions in that area. There seems to be a good case for including such a requirement on the face of the Bill.

Like my noble friend Lord Desai, I am interested in the mechanisms for distributing resources to cope with varying degrees of deprivation both between and within primary care trusts. Populations vary; some will be 100,000 in number. My noble friend has written to me about that, but the response is rather detailed. It would be useful if it could be spelt out more clearly.

Perhaps my noble friend can explain a problem with which I have a little difficulty. It concerns the "independent contractor" status of most GPs and the fact that they are contracted to give services to the National Health Service and are therefore technically "providers". At the same time they will be, initially in primary care groups and then as part of PC trusts (if those come into being), commissioners of hospital services but also of community and primary care services. The split between commissioners (previously known as purchasers) and providers will then be ended despite the Government's stated intention to retain that part of the 1991 legislation. As local GPs will be involved in PCT management board responsibilities, they will in effect be commissioning their own services. The noble Baroness, Lady Thomas of Walliswood, referred to that, as did the noble Lord, Lord Clement-Jones, and others. As a former GP I can well see the advantage of that, but perhaps some sort of "arm's length" mechanism needs to be built in.

Another untidy area involves the boundaries of PCGs and PCTs. Patients do not necessarily register with a doctor in the same catchment area as their home. Many GPs have sizeable parts of their registered practice population living in a different health authority. Practice lists are notoriously inaccurate, especially in inner cities where there is rapid population turnover. That will make it difficult to allocate appropriate resources to PCGs and PCTs. The problem is well discussed by Drs. Gilley and Majeed in the British Medical Journal of 16th January. I hope that the Department of Health will take good note of those helpful articles.

I am quite pleased with much of the remainder of the Bill, in particular the establishment of CHIMP (Clause 14) and, by implication, NICE, although it is not in the Bill. However, best of all is the provision in Clauses 22 and 23 for financial co-operation between local authorities and health authorities. That was well described by my noble friend Lord Warner from his personal background with the social services directorate in Kent. That provision should greatly improve community care and, among other advantages, may speed up the discharge of elderly patients blocking beds. I hope that it will prove to be a further step in the realisation by Government that healthcare and social care merge imperceptibly; or, to put it another way, they overlap. In the community they do so almost from end to end.

I share the anxiety expressed by the noble Lord, Lord Walton, and others, about Clause 47 and Schedule 3. The new powers to amend the regulation of

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the health professions by Orders in Council are accepted by many of the professions as necessary. But not only the BMA but other professions are worried that under paragraph 8(1) of Schedule 3, the Secretary of State could theoretically set up a new professional regulatory body, with the Government paying for it, which would then not be independent as is the GMC now. John Denham, the Minister concerned, has reassured the BMA that the Government would not use that power. However, without that assurance being written into the Bill in some way, a future Secretary of State could bypass the GMC or any other self-regulatory body. I hope that my noble friend can agree to discussions which might lead to a small amendment which will recognise the Government's support for the principle of self-regulation and the protection of the General Medical Council. That will be reassuring to all the healthcare professions and would lead to a continued fruitful working relationship between them and the Department of Health.

7.28 p.m.

Baroness Berners: My Lords, I thank the Minister for her explanation of the Bill, and my noble friend Lord Howe for his lucid dissection. I speak on the Bill as a lapsed, hands-on nurse with many medical friends. The National Health Service, under the stewardship of the Conservative government for more than two-thirds of its existence, has during that time conserved its principles, increased its capabilities, built up and founded good practice and kept up with the rapidly changing face of medicine, technology and the nation's expectations. There is a good foundation on which subsequent governments will continue to build by responding to the changing demands of healthcare and its administration.

The Bill, setting out what the funding of £21 billion is supposed to cover, heralds yet another huge set of pressures on those who administer the service. The legislation and its provisions will never cover the enormous costs engendered either in financial terms or in terms of the potential health risks to the hard pressed, conscientious, compassionate executives, clinicians and caring staff; in fact, all who do their best to promote the health of the nation already under great pressures.

There are far too many radical proposals to carry out at once when, inevitably, there has to be a different reallocation of funds nationwide. So, for example, the search for ways of making more beds available, already a very fraught problem in every area, will still not be possible because, as in East Gloucestershire, the money has been reduced but expenses have been increased. We have seen, for example, the funding of the much welcomed pay award to nurses; financing of the new working time directive; and paying for up-to-date proven drugs. Those are but a few of the mounting needs with their associated high cost. There are no powers to run a deficit; the long suffering public pay the price.

I understand that my own area health trust is dismayed by the huge pressures it will have to bear to deliver an adequate health service. The shift of emphasis from treatment to prevention is acknowledged to be the

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next sensible step in improving the service and is generally welcomed. But the treatment must go on and it is expensive. How can the problem of affording proven treatment be resolved? Thousands of lives are lost every year. Young lives are cut short. What will be said to the parents of young children who are not sufficiently well off to afford the £9,000 drug needed to allow them to bring up their family and not otherwise available to them? Nowadays, people know what is the proven treatment before they visit their GP or consultant. What a dilemma!

When doctors, nurses, patients and their relatives perceive an inefficient hospital trust administration, resulting in bad practice, unhealthy conditions regarding cleanliness, low staff morale and patients' food left untouched, to whom can they turn? Who should they ask to improve conditions? What inspectorates are in place to deal with the situation? Perhaps the new commission has been created for this purpose.

The noble Baroness, Lady McFarlane, expressed the same regret that the regulation of healthcare and associated professions has been relegated to the heading of "Miscellaneous and Supplementary". I would welcome what is listed in Schedule 3, paragraph 1(c)(e) and (f) appearing in Clause 47. That would cover education and training before and after admission to practice; standards of conduct and performance; and discipline and fitness to practice.

I wish to comment briefly on the welcome new strategy for nurses, the super nurse. Have any been appointed yet? By all reports, nurses are in very short supply, resulting in under-staffing. Therefore, wherever nurses are employed they must be working flat out to the best of their abilities in the time they have available. They must have worked out before they joined the service the maximum number of hours they have available. How can they be expected to do even more, even better, without crumbling under pressure? It is a release from pressure that is really needed in all the services.

So yes, we need more nurses, but let us be choosy about recruitment. How carefully are prospective students vetted? There have been reports of a few lazy, insubordinate and intimidating staff in hospital wards. I feel that there should not be an indiscriminate choice of candidates to make an impressive statistic. We are lacking a grade of nurses trained by the bedside both clinically and compassionately, bringing out the practice of common sense for the relief of suffering, including a concern for the anxieties of patients suddenly whisked out of their homes and into unfamiliar surroundings.

By "clinically trained" I do not mean to intensive care standard. That is superbly carried out by our graduate nurses under Project 2000. This new grade of nurse should have as part of her duties the responsibility of helping patients to feed and ensuring that they take nourishment. I know for a fact that this does not happen in every hospital. It is not a difficult thing to do, but it is absolutely vital to recovery. And there is another duty. Everyone who has ever had to spend more than a day in bed knows the feeling of the "numb bum". Why has the practice of preventing bedsores by regular massage

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by nurses been stopped? It is all part of a constant communication between staff and patients. If the disciplines necessary are neglected, hours and hours can go by before a critical condition is noticed. Very often people suffer in silence.

I conclude with the first step into treatment by the National Health Service--the general practitioners. They are well trained, hard working people and the pressures on them mount daily as they are required to do increasing amounts of paperwork. It is not a new problem, but it is getting worse by the day. Their precious time is needed for footwork, not form filling of every type and description. GPs have expressly voiced that concern. Is it all really necessary?

7.37 p.m.

Baroness Sharp of Guildford: My Lords, we have had a wide-ranging debate today which befits the Second Reading debate of a major plank of the Government's legislative programme. As might have been expected, the debate has concentrated on six areas. The first is the three key features of the Bill; the abolition of fundholding GP practices and their replacement by primary healthcare groups and subsequently trusts; and the duty of quality and the duty of partnership. We also debated the Pharmaceutical Price Regulation Scheme; Part II of the Bill which relates to Scotland; and Part III, which is the notorious Clause 47. In winding up from these Benches, I wish to touch briefly on all six issues.

As was clear from the contributions of my noble friends Lady Thomas of Walliswood and Lord Clement-Jones, we on these Benches support the abolition of GP fundholding and its replacement by a broader grouping led by the primary care interests. That said, we have some real reservations about the detail of the Bill and those have been echoed by other speakers in the debate. As my noble friend Lady Thomas said, there is a considerable learning process to be experienced whenever one makes radical changes in institutions. It is by no means clear that the Bill has allowed time or resources for those learning processes, be it the transition from fundholding to primary care groups or the subsequent transition from primary care groups to primary care trusts.

Secondly, as quite a number of contributors to the debate noted, there is considerable vagueness in the primary care trust arrangements. They mix the purchaser and provider role. It is not clear whether cash limits will be imposed and, if so, how they will work. Finally, we are extremely concerned about the governance issues. Who will sit on primary care trust boards? What is the role for the profession? That issue was raised by a number of noble Lords. What is the role of lay members? None of that is clear.

As we have made clear, one of the reasons why we welcome these proposals is that our vision has long been one that would bring together the health service at the local level with local authority social services to provide that seamless web of care services and, indeed, to emphasise the role of public health issues--housing,

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environmental services and education--as major contributors to the health of the nation. Those issues were stressed by the noble Lord, Lord Rea, in his speech.

In other words, for a long time we have wanted to see joined up thinking about health and social care at the local level. But in doing that, I should also like to take on board the issues raised by the noble Lords, Lord Walton and Lord Winston; that is, that it is important to include secondary care as part of the same continuum. One of the faults of the original National Health Service was the separation of the hospital service from primary care, so making the NHS hospital-led. One of the benefits of GP fundholding was to turn that relationship on its head. As the noble Baroness, Lady Fookes, pointed out, it was the GPs who then called the tune. We hope that the primary care trust will maintain the bias that the service should be primary care led. But it is extremely important that the primary and secondary sectors are complementary to each other rather than antagonistic to each other.

Given our welcome for the wider remit of the primary care group and primary care trusts, it is not surprising that we also welcome the second main principle embodied in the Bill; that is, the duty of partnership. But again, there is uncertainty as to precisely what is a duty of partnership. Are the proposed health improvement plans any more than motherhood and apple pie? Like the noble Baroness, Lady Pitkeathley, said, we would wish to see the duty of partnership extended to voluntary sectors and to carers. As we all know, they are essential contributors to today's National Health Service.

I come to the third keystone of the first part of the Bill--the duty of quality. Again, we welcome that commitment. But as my noble friend Lord Mar and Kellie emphasised, it is outcomes not inputs that we should measure in terms of quality. As the noble Baroness, Lady McFarlane, emphasised, we need to set standards not only for medical practice, but also in terms of nursing and care standards. But once again there is a considerable element of vagueness in the Bill. How do we measure quality? Why is the commission for health improvement to inspect the primary care trusts and the hospital trusts but not the health authorities? Will the commission's report be made public? What is the relationship between the commission for health improvement and the Audit Commission?

That last thought raises a further issue about the proposals which worries me. Perhaps because I come from the education sector, whenever I see something that has a monitoring or inspecting role, Ofsted raises its head. One of the problems with the Conservative reforms of the 1980s which introduced market disciplines into the public sector was that we found ourselves being expected to go out into the marketplace and compete and at the same time meet an increasingly detailed set of targets. In effect, the command economy was there and the market economy was there. But I wonder whether, as a nation, we are in danger of going overboard for inspection and monitoring of these things; for naming and shaming. In the very good speech of the noble Baroness, Lady Cumberledge, she stressed

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the importance of the health service as a trust relationship. That is vital. But too much inspection can undermine morale and break that trust relationship.

I should like to speak briefly about three other aspects of the Bill that were discussed today. First, the pharmaceutical price regulation scheme. In my academic role, I have undertaken many studies of the pharmaceutical industry. What I find fascinating about that industry is that it is the only one in the United Kingdom where we have had a consistent industrial policy for almost 40 years. Because we have had a consistent policy, we have managed to build an industry that has become a major player on the global scene.

Going back to the 1980s, Glaxo was a family firm selling dried milk; Wellcome was a company that was not very large and uncertain as to whether it had a public role or was a private company. ICI only began dabbling in pharmaceuticals in the mid-1950s. All those companies, in their different ways, have now become world leaders. An important part of that has been that we, in this country, provided consistent support for the industry. That support has come through the pharmaceutical price regulation scheme. We pay more for our drugs than France and Spain, but we have benefited greatly from new and innovative drugs which have been introduced and developed in this market. They have drastically reduced the cost of the National Health Service itself. For example, Tagamet and Zantac totally transformed the situation in relation to stomach ulcers and, more recently, EPO replaced the need for blood transfusions.

The industry also provided a major stimulus for research in the life sciences in this country. It has been a mutually reinforcing relationship. As the noble Lord, Lord Walton, stressed, we have attracted a great deal of foreign direct investment in this sector--investment in research and development which is high quality investment bringing good quality jobs. But they have come because we have an excellent science base. The industry has contributed also to that science base. It is indeed one of the few examples in Britain where excellence in science is translated into technological and commercial advantage.

We would be ill-advised therefore to throw away a scheme which, to my mind, has benefited the industry so substantially. But that said, there are limitations. The noble Lord, Lord Ewing, emphasised the fact that their profits are considerable and there are occasions when the industry has been known to overcharge. I do not believe the scheme provides enough incentives to keep costs down and the whole process is much too secretive. It should be, within the limits of commercial confidentiality, much more open and above board. But having said that, it is important that we do not throw the baby out with the bath water. We on these Benches would favour the retention of a voluntary scheme, if possible. We do not like the idea of a hybrid scheme, half voluntary and half statutory. If a voluntary scheme cannot be negotiated, we feel that there should be a statutory scheme.

I do not want to say much about the health service in Scotland because that is not an area that I know much about. The point made by the noble Baroness, Lady

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Carnegy of Lour, struck me as interesting; that is, how extraordinary it is that such extensive changes are being proposed now when in five months' time the responsibility for running the health services in Scotland will rest with the Scottish Parliament. That said, exactly the same criticisms seem to apply to the provisions relating to Scotland as to those relating to England and Wales; namely, that they are still too vague and we do not know precisely what is being proposed.

I turn to Clause 47 and Schedule 3, the so-called Henry VIII provisions. I was struck by the remarks of the noble Baroness, Lady McFarlane, when she said how appalled she was that the Bill could appear without waiting for the consultation process with the professional bodies to be concluded. That, together with the fact that so much is left to delegated powers--even if under the affirmative resolution procedure--makes that clause extraordinarily unsatisfactory. The Bill should specify the key elements in the Government's structure.

From these Benches, there is broad agreement with the general principles of the Bill, but the devil is in the detail--perhaps I should say that the devil is in the lack of detail. We disagree with much of that detail. My noble friend Lord Clement-Jones made clear from these Benches that we do not support the amendment. We believe that the deficiencies in the Bill should be dealt with in Committee and be challenged then by amendment and the process of debate.

7.52 p.m.

Lord McColl of Dulwich: My Lords, I, too, thank the Minister for her clear exposition of the Bill and, as my noble friend Lord Skelmersdale mentioned, for the Explanatory Notes. I am grateful also to my noble friend Lord Lyell for declaring my interests in the National Health Service!

As I listened to Labour Peers attacking the GP fundholding concept I was left wondering whether they had ever spoken to Professor Brian Abel-Smith, one of the most brilliant advisers the Labour Party ever had. He told them, "Whatever you do, don't get rid of GP fundholding because it has been a success". How sad that the Government did not accept his advice.

The beauty of GP fundholding was that it was voluntary. That was a sensible arrangement because GPs are independent contractors. To be fair to the Government, the Labour Party's White Paper said that fundholding had brought real benefits to patients, as my noble friend Lord Howe mentioned.

The Labour Party's answer to GP fundholding is to have a compulsory system whereby groups of between 50 and 100 GPs are dragooned into primary care groups. I was fascinated by the speech of the noble Lord, Lord Desai. I believe that he is absolutely right when he says that between 50 and 100 GPs in such a group would be far too many. It is difficult enough to get five professionals to agree on anything, let alone 50 or 100. I am sure that that applies to economists as well as to doctors.

General practitioners will no longer be able to act individually. It is very likely that the system will reduce the ability of GPs to offer such a wide range of services,

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reduce their ability to secure improvements in the hospital service, and tend to reduce incentives for them to provide a more efficient service.

We on these Benches have the distinct impression that the Labour Party is rather hostile to the freedom which general practitioners have been enjoying. Sadly, the way in which the resources will be allocated will leave little room for incentives to make the savings at practice level as efficiency gains will tend to be swallowed up by the whole primary care group.

As has been mentioned, the combination of national institute for clinical excellence best practice guidelines plus the cash-limited prescription budgets will certainly shackle the GPs' ability to decide what is the best treatment in the best interests of the patients. Behind all that there is a feeling among GPs that the Government want to shift on to the profession the blame for the present rationing and that those in the profession will carry the can for the rationing imposed by Whitehall.

The Labour Party has always criticised GP fundholding as being a two-tier system for patients. However, as many noble Lords have pointed out, the Government are introducing a four-tier system. Dr. John Chisholm, chairman of the British Medical Association's GPs' committee, stated:

"People in different parts of the UK will receive different levels of service".

The problem is that, whereas with GP fundholding patients were usually able to choose the fundholding GP, under these arrangements there will be no choice; patients will simply be assigned to the primary care group on the basis of where they live. As has already been described, it will be a four-tier service on the basis of the postcode.

I have always found curious the Government's claim that they are abolishing the internal market. I thought that the Labour Party had turned its back on nationalisation and was in favour of the marketplace. However, as the noble Lord, Lord Desai, hinted, the Government have not abolished the internal market; they have retained the purchaser/provider split which is the essence of an internal market. The window-dressing which they have used is to say, "The evidence that we've abolished the internal market is that we have a new statutory duty of co-operation. Our health service trusts will be legally required to work in partnership".

Clause 19, as we have mentioned already, states that it is the duty of health authorities, special health authorities, primary care trusts and NHS trusts to co-operate with each other in exercising their functions. How on earth will that be enforced? As my noble friend Lady Fookes pointed out, that sounds like a lot of waffle. Perhaps the Labour Party might try to extend the principle to other parts of the market, such as the commercial world, encouraging companies to co-operate with each other in exercising their functions.

Many references have been made to CHIMP and NICE. CHIMP is the body responsible for enforcing guidance produced by NICE. The set-up will certainly provide the Government with a means of increasing

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rationing, but will the search by NICE for evidence-based medicine include the various branches of alternative medicine?

As regards the role of CHIMP as a device for monitoring clinical quality, it will have the powers of absolute privilege in respect of any publications. It seems that CHIMP will have wide-ranging powers and functions, including a power to enter and inspect NHS premises at any time and force the compilation of reports. Failure to comply could result in conviction and a fine. The profession increasingly sees that as a severe threat to its autonomy. The BMA's chairman, Dr. Ian Bogle, pointed out that CHIMP could lead to doctors losing their clinical freedoms. I think he is right.

For many noble Lords--including the noble Lord, Lord Walton of Detchant, the noble Baroness, Lady McFarlane of Llandaff, and my noble friend Lord Howe--the most ominous parts of the Bill are Clause 47 and Schedule 3, which will enable the Secretary of State to undermine the whole structure of self-regulation by ministerial decree. That is most worrying.

Many of us have been state employees for a long time but it has not felt like it. The new regime will feel very oppressive. It is not only doctors who will be affected by these draconian measures. They will affect other health professions not already under statutory regulation and could extend to new professions that have not yet emerged. An Act of Parliament will not be required but only an Order in Council. The Government have reacted in a knee-jerk fashion to recent cases that received an enormous amount of publicity, such as Bristol. It seems that the Government are seizing the opportunity to reduce the independence of the medical profession. That will impair the doctor-patient relationship, and will ultimately be harmful to patients.

I cannot help wondering why the Government are involving themselves in this great upheaval when the real problem is morale. The noble Lords, Lord Walton and Lord Winston, pointed out that there is no mention in the Bill of the university side, which desperately needs more resources and encouragement. The noble Lord, Lord Winston, mentioned that my noble friend Lord Howe had spoken about GPs and clinicians. I should explain that my noble friend is a distinguished classicist and knows that "clinic" is a Greek word meaning bed, so clinicians are bed people. That explains a lot. GPs do not tend to have beds.

As to morale, thousands of patients are demoralised. They have been denied NHS operations for varicose veins, sebaceous cysts and lipomas. Many of those people are poor and cannot afford to have their operations done privately. Why do the Government continue refusing to help those poor people? Why cannot the Government use some of the £22 billion that they keep telling us about to allow those operations to be undertaken by the NHS? Are they worried that would increase the number of patients on waiting lists?

Another source of poor morale in the NHS is the gross imbalance between the number of consultants and junior staff. There are far too few consultants and far too many junior staff. Even worse, they have been

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training for 20 years and, at the end of it, they find that they have no job. The NHS is a monopoly employer so there is nowhere for those people to go. What an appalling waste of scarce resources and a tragedy in human terms. What are those junior staff supposed to do?

Last week, the Minister kindly wrote to reassure me that none of those junior staff members would be out of a job. I recommend that she speaks to the 13 or 14 postgraduate deans, who have a very different story to tell. There is a desperate need for more consultants in psychiatry, accident and emergency, cardiology, cardiac surgery, oncology, palliative care and obstetrics. Why do not the Government make a serious effort to create 20 or 30 more consultant posts in all those specialties this year, bearing in mind that £22 billion is available? Will the Minister provide some hope for those beleaguered junior staff members? They have made a great contribution to the service. If the Minister could take steps to increase the number of consultants, it would go some way to reassuring the NHS at a time when it is reeling from the prospect of this draconian Bill.

We look forward to the Minister's replies to the many questions that have been asked and fears expressed about the Bill. We particularly look forward to a detailed answer to the amendment proposed by my noble friend, Lord Howe.

8.5 p.m.

Baroness Hayman: My Lords, when speaking in your Lordships' House one often has the feeling that one is stepping through a looking glass, if not in Wonderland. The idea of an NHS reeling from the threat of this "draconian Bill" bears little resemblance to reality. In the real world of doctors and nurses, they are more interested in the pay review, a successful recruitment campaign for nurses, the day-to-day conditions in which they work and the pressures, as we all recognise, that they face.

This important Bill deserves scrutiny and many detailed issues have been raised in the debate. I hope the House will understand that I shall not be able to reply to every point in the course of this speech but there will be many opportunities to deal with them in the later stages of the Bill's passage through the House. There will be facilities for any noble Lord to discuss specific points of clarification.

I do not deny that the Bill is complex. I am grateful to the noble Lord, Lord Skelmersdale, and others for their kind comments about the explanatory notes. Even so, we are dealing with complex legislation that amends previous legislation, which itself amended previous legislation. I hope that a meeting before Committee stage will be helpful in dealing with points of clarification.

I do not deny for a moment that serious issues have been raised to which I alluded in my opening speech--perhaps predominantly that of self-regulation. That is a real concern to the professions, government and patients. After all, the Bill is about ensuring safety for patients. It is in everybody's interests that we get those

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issues right. I look forward to debating the detail. I listened intently to the comments of the noble Lord, Lord Walton, and the noble Baronesses, Lady McFarlane and Lady Emerton. We will not only scrutinise but may change the Bill in the course of its passage to achieve what I believe are mutually agreed aims. That is absolutely appropriate for the way in which your Lordships' House conducts its business.

I have to say that I found it uncharacteristically provocative of the noble Earl to table an amendment at this stage in the passage of the Bill.